1235118043 NPI number — AUGUSTA RETINA LASER SURGICARE

Table of content: (NPI 1235118043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235118043 NPI number — AUGUSTA RETINA LASER SURGICARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUGUSTA RETINA LASER SURGICARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235118043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-3035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-210-0305
Provider Business Mailing Address Fax Number:
706-210-0306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3685 WHEELER RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-6446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-210-0305
Provider Business Practice Location Address Fax Number:
706-210-0306
Provider Enumeration Date:
01/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BECKER
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
706-243-2259

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ASC025 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000874794A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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